Medicine in the Northern Territory works a little differently than in other states.
Up north crocodiles outnumber endocrinologists, which is unfortunate because crocs are terrible at explaining HbA1c.
Vast distances, poverty, and language and cultural differences make it difficult for people in the territory to live their healthiest lives – especially Aboriginal and Torres Strait Islander people.
For Dr Anna Wood, endocrinologist in the NT and researcher with Menzies School of Health Research, this means the endocrine system barely makes the top ten of complicated systems she has to navigate every day.
Bureaucracy, geography, culture, and understaffing all mean that Territory health workers have to constantly look for clever workarounds to difficult problems – and what they’ve figured out could improve healthcare for us chilly folks down south too.
Diabetes type too many
Endocrinology in the NT is primarily about type two diabetes, but not the kind we all know and loathe.
“We have the highest rates of young-onset type two diabetes in the world, and very high rates of diabetes in general” notes Anna.
In other parts of the world, people usually develop type two diabetes after they’ve had kids, in their forties and fifties.
But in the Northern Territory, people are getting diabetes in their teens and twenties, and if they get pregnant their babies also experience high sugar levels in the womb. That makes it more likely for the next generation to get diabetes young too.
“Often women will be diagnosed in their teens with [type two] diabetes, and they come into pregnancy already having diabetes. We describe this as the intergenerational cycle of diabetes.”
“Apart from First Nations people in other countries, we aren’t seeing type 2 diabetes pre-pregnancy in other populations. The evidence in this field is still evolving, but it really does look like if your mum has type two diabetes in pregnancy that you’re very predisposed to getting diabetes yourself.”
This is a real problem for people up north, and the solution isn’t simple.
“I think a lot of why diabetes is so high is because of the social determinants of health that are negatively influencing health equity” says Anna.
“It’s very difficult to access healthy affordable foods and safe places to exercise, and there’s overcrowded housing, so all of that makes it very difficult to have a healthy lifestyle – and then there’s a lot of intergenerational trauma.”
Endocrinologists have been looking at chronic stress for years to see how it wears the body out. That wear and tear is called allostatic load, and the more it stacks up the higher the chance of something going bung.
It’s how everyday constant stress like poverty, racism, or trauma literally become a pain in the neck (or knee, or stomach, or chest).
“There’s very good evidence that when people are chronically stressed it increases your inflammation and increases your risk of diabetes” Anna observes.
Not just blood sugar
Compounding all this is shame. When type two diabetes is seen as an old person’s disease and talked about as something preventable, it’s easy to assume that there must be something wrong with you for having it.
Anna sees this stigma affecting young Aboriginal women. “If you Google ‘diabetes’ you might get an old Caucasian man or something. How can you relate to this person?”
“Then there’s this idea that diabetes is a lifestyle condition so it’s natural for people to think that it’s their fault. That’s a lot of the shame and stigma.”
The effects of this shame are profound – people might go without medicine, or hide away to check their blood sugar levels.
“We’ve done quite a lot of qualitative research … and some of the key findings were really interesting. People say ‘I don’t want to talk about this, I don’t want people to know I’ve got diabetes.’ And on the flip side, there’s this inevitability about it – this idea that my mum has diabetes, my grandma has diabetes, so of course I’m going to get diabetes. Many people I know are on dialysis, so this is my story.”
When up to 30% of your community has type two diabetes, it can feel like you’re doomed to get it too.
Chipping away at the problem
Originally coming from Melbourne, Anna was shocked to discover that shops in small communities often only stock soda or overpriced bottled water. In the tropical heat, this leaves residents with the choice of cold sugary drinks or warm tap water.
While efforts are currently underway to help stores stock cheaper and healthier options, geography makes things tricky.
“A typical community in the Northern Territory would be a store or a couple of stores where food is often very expensive” she explains.
“You can imagine, the food has to come from Darwin or Adelaide, and during the wet season, it’s very hard because it’s coming on a barge or a plane. So the fresh fruit and veg by the time it gets there, it’s already 10 days old.”
“So it ends up so much easier and cheaper to just get a pie or chips”
Darwin evolution (of the health system)
Given the barriers from limited healthy food to intergenerational stress, the medical solution isn’t always about prescribing more pills.
In the Northern Territory, relationships often come first, and doctors aren’t the ultimate authority. Rather than seeing a specialist – often a non-Indigenous person who’s flown in – patients might get advice from a trained local who understands what it’s like.
“The Aboriginal workforce is so important to have on the ground,” says Anna. “What we need is Aboriginal Health Practitioners, navigators, coordinators, community workers and support people who can help patients through their health journey, particularly when they have multiple chronic conditions like diabetes and obesity.”
Specialists are special people, but that’s not always enough when you’re responsible for an area the size of France.
Sometimes, Anna says, you don’t need one at all: “Do you really need to see an endocrinologist could you see a diabetes educator or a nurse?”
Rather than having one endocrinologist from out of town, Anna argues much of the focus should be on supporting and focusing on the local workforce.
Training local people to help with specific aspects of care helps relieve the chronic understaffing in the NT health system as well as make medicine less intimidating for patients.
Making the message stick
Territorians are used to clever outsiders swooping in with grand promises to sort everything out. Without community involvement, even the most well-intentioned projects will flop.
Successful health strategies must come from consultations with the people most affected, Anna says.
And when working with all different sorts of people, communication also needs to become more adaptable.
Depending on the patient, Anna’s explanations of diabetes could involve a deep dive into HbA1c, but she might also use metaphors to help her patient visualise what’s going on in their body.
Diabetes is a sneaky disease – people can go for years feeling kind of meh while their kidneys slowly go downhill. Because it takes so long to get serious, it’s often hard for people to really understand what’s happening.
But we all know that sweet things are sticky, and thick sticky liquids flow slower. So that’s how Anna explains high blood sugar to make diabetes more relatable.
“High sugar in the blood means that your blood is sticky, and so it means that you can’t get the blood to the places it needs to go. So it makes you fuzzy in the head, it affects the blood supply to your feet, and it makes you feel just a bit rubbish. And so we need to get the sugar better.”
This kind of everyday language makes medical information more accessible and understandable for people who aren’t doctors.
Learning from the best
“What I’ve learned is that I am not the expert, that people living with the conditions are the experts” says Anna.
“They’re the ones that we need to listen to and work with, and my Aboriginal colleagues and mentors have taught me this.”
Medical school teaches students to look into other people’s hearts, not their own. That’s something doctors have to learn on the job, but it can take a while.
Anna’s seen this play out first-hand.
“The biggest thing I see that doctors do, is that they think that they know best.”
“There’s this idea of ‘Yeah, I’m in a remote community, I’m an endocrinologist, you should be happy to have me here.’ And it’s just not the case. I’m the one who’s it’s privileged to be here on Aboriginal land.”
Medicine up north isn’t about flying in to fix everything; it’s about staying, listening, and supporting people with the things they would like support with, in a way that best meets their needs.
In a place as vast and beautiful as the NT, it turns out that knowing the people, the place, and the problems often beats knowing every detail of the pancreas.
